Clinician challenges to evidence‐based prescribing for heart failure and reduced ejection fraction: A qualitative evaluation

Trinkley, Katy E.; Dafoe, Ashley; Malone, Daniel C.; Allen, Larry A.; Huebschmann, Amy G.; Khazanie, Prateeti; Lunowa, Cali; Matlock, Daniel D.; Suresh, K.; Rosenberg, Michael; Swat, Stanley A.; Sosa, A.M.; Morris, Megan A.

doi:10.1111/jep.13885

Cited by 3 publications

(1 citation statement)

References 47 publications

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“…Finally, guidelines and recommendations pose a challenge to the optimization of treatment because they are not particularly patient-centred and do not necessarily acknowledge the challenges of a real-world population. 72,73 Hence, understanding and addressing these components might improve overall outcomes of patients with HFrEF.…”

Section: Factors Associated With Suboptimal Treatment: Potential Caus...mentioning

confidence: 99%

Optimization of GDMT for patients with heart failure and reduced ejection fraction: can physiological and biological barriers explain the gaps in adherence to heart failure guidelines?

Jarjour,

Ducharme

2023

DIC

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Heart failure is a growing epidemic with high mortality rates and recurrent hospital admissions that creates a burden on affected individuals, their caregivers and the whole healthcare system. Throughout the years, many randomized trials have established the effectiveness of several pharmacological therapies and electrophysiological devices to reduce hospitalizations and improve quality of life and survival, mostly for patients with heart failure with reduced ejection fraction (HFrEF). These studies led to the publication of national societies' recommendations to guide clinicians in the management of HFrEF. Yet, many reports have shown significant care gaps in adherence to these recommendations in clinical practice, highlighting suboptimal use and/or dosing of evidence-based therapies. Adherence to guidelines has been shown to be associated with the best prognosis in HFrEF, with patients presenting with intolerances or contraindications having the highest risk of events; however, it remains unclear whether this association is causal or merely a marker of more advanced disease. Furthermore, individual characteristics may limit the possibility of reaching the targeted dosage of specific agents. Herein, we provide a comprehensive overview of clinicians' adherence to heart failure guidelines in a specialized real-life setting, particularly regarding use and optimization of guideline-derived medical therapies, as well as the implementation of more recent agents such as sacubitril/valsartan and SGLT2 inhibitors. We seek potential explanations for suboptimal treatment and its impact on patient outcomes.

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Section: Factors Associated With Suboptimal Treatment: Potential Caus...mentioning

confidence: 99%

Optimization of GDMT for patients with heart failure and reduced ejection fraction: can physiological and biological barriers explain the gaps in adherence to heart failure guidelines?

Jarjour,

Ducharme

2023

DIC

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Barriers and Facilitators to Heart Failure Guideline-Directed Medical Therapy in an Integrated Health System and Federally-Qualified Health Centers: A Thematic Qualitative Analysis

Philbin,

Gleason,

Persell

et al. 2024

Preprint

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Background: Clinical guidelines recommend medications from four drug classes, collectively referred to as quadruple therapy, to improve outcomes for patients with heart failure with reduced ejection fraction (HFrEF). Wide gaps in uptake of these therapies persist across a range of settings. In this qualitative study, we identified determinants (i.e., barriers and facilitators of quadruple therapy intensification, defined as prescribing a new class or increasing the dose of a currently prescribed medication. Methods: We conducted interviews with physicians, nurse practitioners, physician assistants, and pharmacists working in primary care or cardiology settings in an integrated health system or Federally Qualified Health Centers (FQHCs). We report results with a conceptual model integrating two frameworks: 1) the Theory of Planned Behavior (TPB), which explains how personal attitudes, perception of attitudes of others, and perceived behavioral control influence intentions and behaviors; and 2) The Consolidated Framework for Implementation Research (CFIR) 2.0 to understand how multi-level factors influence attitudes toward and intention to use quadruple therapy. Results: Thirty-one clinicians, including thirteen eighteen (58%) primary care and (42%) cardiology clinicians, participated in the interviews. Eight (26%) participants were from FQHCs. A common facilitator in both settings was the belief in the importance of quadruple therapy. Common barriers included challenges presented by patient frailty, clinical inertia, and time constraints. In FQHCs, primary care comfort and ownership enhanced the intensification of quadruple therapy while limited access to and communication with cardiology specialists presented a barrier. Results are presented using a combined TPB-CFIR framework to help illustrate the potential impact of contextual factors on individual-level behaviors. Conclusions: Determinants of quadruple therapy intensification vary by clinician specialty and care setting. Future research should explore implementation strategies that address these determinants by specialty and setting to promote health equity.

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Physician Perceptions of Medication Prescribing in Heart Failure: A Scoping Review

Vasudevan,

Thayaparan,

Teng

et al. 2024

Cardiology

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Introduction: The swift uptake of new medications into clinical practice has many benefits, however slow uptake has been seen previously with other guideline-directed medical therapies (GDMT) in heart failure (HF). Sodium glucose co-transporter 2 inhibitors are a novel therapy in HF proven to be efficacious and will have beneficial clinical outcomes if prescribed. Understanding physician perspectives on prescribing GDMT in HF can help target strategies to bridge the gap between guidelines and practice. Methods: The study followed the PRISMA guide for scoping reviews and the JBI Manual for scoping reviews. A search was conducted using EMBASE, Medline and PubMed databases in April 2024. Studies included were those using qualitative methods to assess physician perspectives towards prescribing any HF medication. Common themes were identified through thematic synthesis following the methods from Cochrane Training and using software MAXQDA Analysis Pro. Results: 708 studies were found in the search, with 23 full studies included. The most pertinent barriers identified were concern for medication adverse effects, unclear role responsibilities between physicians of different specialties, patient comorbidities and unwillingness to alter therapies of stable patients. The most identified enablers included awareness of efficacy, influence from colleagues and the use of multi-media approaches for information dissemination. Perceptions were also found to change over time and vary among prescriber groups. Conclusions: Physicians perceive common barriers and enablers of prescribing GDMT in HF, despite differences in prescriber groups and time periods. The identified barriers and enablers may be targeted to improve implementation of GDMT into clinical practice.

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Clinician challenges to evidence‐based prescribing for heart failure and reduced ejection fraction: A qualitative evaluation

Cited by 3 publications

References 47 publications

Optimization of GDMT for patients with heart failure and reduced ejection fraction: can physiological and biological barriers explain the gaps in adherence to heart failure guidelines?

Optimization of GDMT for patients with heart failure and reduced ejection fraction: can physiological and biological barriers explain the gaps in adherence to heart failure guidelines?

Barriers and Facilitators to Heart Failure Guideline-Directed Medical Therapy in an Integrated Health System and Federally-Qualified Health Centers: A Thematic Qualitative Analysis

Physician Perceptions of Medication Prescribing in Heart Failure: A Scoping Review

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